Post test-CPH-Section D

1. Roland San Jose, a 20-year-old client has arrived in the post-anesthesia care unit (PACU) after having a
tracheostomy. All of the following interventions are included in the standardized post-tracheostomy plan of
care. Which action should the nurse take first?
a. Suction as needed.
b. Clean tracheostomy inner cannula and stoma.
c. Listen to lung sounds.
d. Change tracheostomy dressing as needed.
Rationale: Listening for breath sounds should be accomplished before suctioning, because suctioning may not
be needed if breath sounds are clear. The other interventions are not needed for airway maintenance, which is
the primary goal for a client with an artificial airway.
2. All of the following clients are assigned to the RN working on a medical unit. Which client has the most
urgent need for assessment or intervention by the RN?
a. A client admitted 2 hours previously with emphysema and increased dyspnea who is receiving
50% oxygen through a Venti-mask
b. A client who has had a tracheostomy for 1 week and who has foul-smelling drainage on the
tracheostomy ties and needs to have the ties changed
c. A client who is anxious to go home and is being discharged with a new prescription for home oxygen
therapy
d. A client who was admitted the previous day with pneumococcal pneumonia who is complaining of
pleuritic chest pain and asking for codeine
Rationale: A client with COPD who is receiving oxygen at levels higher than 40% is at risk for suppression of
the respiratory drive. This client should be assessed at frequent intervals while receiving oxygen at high
levels.
3. Ron Alban is admitted with a diagnosis of laryngeal cancer and scheduled for a total laryngectomy. The
standardized laryngectomy plan of care includes all of the following interventions. Which intervention will be
most important for the nurse to accomplish before the surgery?
a. Discuss appropriate clothing to wear that will help cover the laryngectomy stoma and decrease
social isolation after surgery.
b. Establish a means for communication during the immediate postoperative period, such as a
“magic slate” or an alphabet board.
c. Teach the client and significant others about how to suction the stoma and do wound care around
the stoma.
d. Educate the client about ways to avoid aspiration when swallowing after the surgery.
Rationale: The preoperative teaching should focus on the immediate postoperative concerns, such as a means
of communication. Because the client is likely to be anxious, it is important not to overload the client with too
much information about care after discharge, which is unlikely to be retained and which may increase anxiety.
Aspiration is not a risk after a total laryngectomy, because there is no connection between the mouth and the
respiratory system.
4. The registered nurse is caring for a client with lung cancer who has just been admitted to the ICU after having
a pneumonectomy. The client is intubated and being ventilated with a positive pressure ventilator. All of the
following orders are received. Which one will the nurse implement first?
a. Morphine sulfate 6 to 10 mg IV for pain
b. Continuous pulse oximetry to keep O2 saturation at 92% to 100%
c. Ceftriaxone (Rocephin) 500 mg IV every 6 hours
d. Infusion of one unit packed red blood cells over 2 hours
Rationale: All of the listed interventions are important, but the priority concern after surgery is airway
management and oxygenation.
5. The change of shift report on the hospital medical surgical unit has just been completed. Which of these
clients will the oncoming nurse need to assess first?
a. An asthmatic client who was admitted 1 hour ago with expiratory wheezes and a respiratory
rate of 34 breaths/min
 b. A client with lung cancer who needs an IV antibiotic administered before going to surgery
c. A hospice client with terminal pulmonary fibrosis and an oxygen saturation of 89%
d. A client with COPD who is ready for discharge, but is not able to pay for the prescribed home
medications
Rationale: This client is having an acute asthma attack and should be assessed immediately. The other clients
also require complex nursing care, but are more stable than the client admitted with asthma.
6. A client with chronic bronchitis exacerbated by pneumonia is complaining of increased shortness of breath
and has inspiratory and expiratory wheezes. All of the following medications are ordered. Which one should
the nurse administer first?
a. Salmeterol (Serevent) 2 inhalations
b. Albuterol (Proventil) 2 inhalations
c. Ipratropium (Atrovent) 2 inhalations
d. Triamcinolone (Azmacort) 2 inhalations
Rationale: The client’s dyspnea and wheezing indicates a need for immediate bronchodilation. The rapidly
acting beta2 agonists are the recommended treatment for acute airway narrowing. The other medications are
more appropriate for long-term prevention of bronchospasm or inflammation.
7. You are caring for a 55-year-old man with bilateral pneumonia resulting from aspiration after alcohol
intoxication. Of the following orders, which would you implement first?
a. Draw anaerobic and aerobic blood cultures.
b. Refer to social worker regarding alcohol treatment options.
c. Hang Levaquin 500 mg IV with normal saline at 100 mL/hr.
d. Give Ativan 1 mg PO at bedtime and as needed for agitation.
Rationale: Obtaining the blood cultures before hanging the antibiotics is standard practice. This enables the
result to not be altered by infusing antibiotics. Ativan and referral to social worker should follow, but are not
appropriate to implement first.
8. The medical-surgical unit you are working on has one bed left that is negative airflow. There are four clients
in the emergency department who need to be admitted to a bed. Of the following clients, which one should
you accept on your unit?
a. The 92-year-old woman with bacterial lower lobe pneumonia and a blood pressure of 70/50
b. The 84-year-old man with respiratory distress and who is currently on 100% oxygen
c. The 65-year-old man with right empyema who has a chest tube and a fever of 103.2° F
d. The 45-year-old woman with suspected pulmonary tuberculosis who currently has
hemoptysis
Rationale: This unit has a negative airflow bed, which is appropriate for the client with suspected tuberculosis
and the other clients warrant admission to units with higher levels of care.
9. Which of the following clients should the medical-surgical nurse consider transferring to the intensive care
unit?
a. The 75-year-old client with a diagnosed pulmonary embolism who is receiving heparin and
who currently is experiencing hemoptysis
b. The 63-year-old client with deep vein thrombosis receiving low–molecular-weight heparin and
who has no calf pain
c. The 59-year-old client with a right pneumothorax currently being treated with a chest tube and
oximetry of 96% on room air
d. The 30-year-old client with a history of being intubated 3 days ago and is currently on nasal
cannula oxygen with clear lung sounds bilaterally
Rationale: This client is showing signs of either pulmonary infarction or bleeding abnormality secondary to
the heparin. This indicates decline in status and warrants more close monitoring in the intensive care unit
10. Of the following orders which would the nurse do first on a client who was intubated 30 minutes ago for acute
respiratory distress syndrome?
a. Hang Levaquin 500 mg IV and D5 ½ normal saline.
 b. Obtain aerobic and anaerobic sputum culture.
c. Increase ventilator rate as needed to keep between 16 and 20 breaths/min.
d. Obtain arterial blood gases (ABGs) and pulmonary wedge pressure via the arterial line.
Rationale: Obtaining ABGs after intubation is essential in assessing whether the intubation is effective in
improving oxygenation.
11. Which of the following clients need immediate attention?
a. The 89-year-old male ventilated client intermittently coughing
b. The 74-year-old female ventilated client with noted tracheal deviation
c. The 57-year-old male client recently extubated and complaining of a sore throat
d. The 40-year-old woman on BiPAP for asthma and with increased anxiety
Rationale: This client is showing signs of a tension pneumothorax that could lead to obstructive shock if not
addressed promptly.
12. The nurse is caring for a client who has been admitted with chest pain of unknown etiology. All of the
following laboratory tests are obtained. Which test results require the most immediate action by the nurse?
a. Troponin T is elevated.
b. Creatinine kinase is decreased.
c. Myoglobin is increased.
d. High-density lipoproteins are decreased.
Rationale: Troponin T is a specific marker for myocardial injury, which indicates that the chest pain is caused
by acute coronary syndrome. To minimize the possibility for myocardial muscle loss, the client needs
immediate interventions (e.g., angioplasty, administration of anticoagulants, and administration of fibrinolytic
medications) to improve myocardial perfusion.
13. All of the following information is obtained by the nurse who is admitting a client for a coronary arteriogram.
Which information is most important to report to the physician before the procedure begins?
a. The client has had intermittent substernal chest pain for 6 months.
b. The client develops wheezes and dyspnea after eating crab or lobster.
c. The client reports that an arteriogram done 5 years ago was negative for coronary artery disease.
d. The client has peripheral vascular disease and the dorsalis pedis pulses are difficult to palpate.
Rationale: The contrast agent injected into the coronary arteries during the arteriogram is iodine based. The
client with a shellfish allergy is likely to have an allergic reaction to the contrast and should be medicated
before the procedure with an antihistamine or steroid.
14. The nurse is caring for a client with unstable angina. The cardiac monitor shows ventricular tachycardia. What
action is appropriate to implement first?
a. Defibrillate at 200 J.
b. Check the client.
c. Cardiovert at 50 J.
d. Administer lidocaine 75 mg IV.
Rationale: The nurse needs to assess the client to determine stability before proceeding with further
interventions.
15. You are assisting in the care of a 50-year-old woman who has ingested cocaine. The cardiac monitor shows
tachycardia converted to ventricular fibrillation. Of the following tasks, which is of top priority?
a. Defibrillate at 200 J.
b. Establish IV access.
c. Place oral airway.
d. Obtain arterial blood gases.
Rationale: Defibrillating is of priority before any other resuscitative measures according to Advanced Cardiac
Life Support protocols.
16. Of the following clients, which should the nurse assess first?
 a. The 45-year-old client on a nitroglycerin drip for chest pain who has a blood pressure of 98/46
and has pain rated as 1 out of 10 located midsternum
b. The 56-year-old on client who has received Lasix 40 mg IV and morphine 4 mg IV on the
previous shift for increased crackles in lower lung fields
c. The 68-year-old client on a nesiritide drip for congestive heart failure who is in a normal sinus
rhythm and oxygen saturation is 95%
d. The 79-year-old client admitted for rapid atrial fibrillation who has received digoxin IV and
is recently gone into bigeminy
Rationale: This client may be showing signs of digoxin toxicity with the increased premature ventricular
contractions. Further assessment is warranted and should precede assessment of the other clients.

17. Which of the following statements indicates the caregiver does not understand proper care of the client with
peripheral arterial disease of the lower legs?
a. “The client should drink fluids to decrease risk for viscous blood.”
b. “We must remind the client to refrain from wearing restrictive clothing.”
c. “The client should apply heat directly to the legs in order to promote blood circulation.”
d. “The client should be encouraged to stop smoking because it increases the vasoconstriction of the
arteries.”
Rationale: Heat should not be applied directly to the skin due to risk of burns. The RN should further educated
the caregiver in regard to this intervention.
18. To enhance the percutaneous absorption of nitroglycerin ointment, it would be most important to select a site
that is:
a. Muscular
b. Near the heart
c. Non hairy
d. Over a bony prominence
Rationale: Skin site free of hair will increase absorption. Avoid distal parts of the extremities due to decreased
absorption.
19. Llaurern, a 40 year old woman visits the clinic with complaints of right calf tenderness and pain. It would be
MOST important for the nurse to ask which of the following question?
a. “Do you exercise excessively?”
b. “Have you had any fracture in the last year?”
c. “Are you under a lot of stress?”
d. “What type of birth control do you use?”
Rationale: increased risk of DVT with oral contraceptives
20. Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following
physiologic functions?
a. Bowel function
b. Peripheral sensation
c. Bleeding tendencies
d. Intake and out put
Rationale: All blood components are decreased in aplastic anemia include thrombocytes which increases
patient’s risk to bleed
21. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is
contraindicated with the client?
a. Administering Heparin
b. Administering Apixaban
c. Treating the underlying cause
d. Replacing depleted blood products
 Rationale: Bleeding follows after clotting proteins are consumed in DIC. Administering apixaban, a Factor Xa
inhibitor may result to fatal bleeding.
22. You are preparing a plan of care for a 25-year-old male admitted in sickle cell crisis. You would prioritize
which of the following interventions to prevent further sickling of the RBCs?
a. Taking hourly blood pressures with mechanical cuff
b. Encouraging fluid intake of at least 200mL per hour
c. Position in high fowler’s with knee gatch raised
d. Administering Tylenol as ordered
Rationale: One common trigger of thromboembolic crisis in sickle cell disease is dehydration.
23. You are assigned to care for patient Paul Samson, 37 years old, with diagnosis of Pernicious Anemia. Of the
following assessment data, which is most consistent with the diagnosis?
a. A weight loss of 10 pounds in 2 weeks
b. Complaints of numbness and tingling in the extremities
c. A red, beefy tongue
d. A hemoglobin level of 12.0gm/dL
Rationale: Pathognomonic in pernicious anemia is Hunter’s glossitis, characterized as beefy red tongue. It is
an early clinical sign of vitamin B12 deficiency.
24. While asking a 40 y/0 patient who is suspected of having pernicious anemia of his health history. He
mentioned about possible factors that may have contributed to the condition. Select all possible contributory
factor to his condition?
a. Vegan but eats fish and egg
b. Age
c. Intake of metformin 500mg TID for years now
d. Long term intake of PPI
e. Weight gain of 5 Kg for the past 5 months
Rationale: Long term intake of PPI and metformin affects absorption of Vit B 12.
25. Which of the following assessment is common to pernicious anemia but not to some other types?
a. Difficulty in breathing after exertion
b. Numbness and tingling in the extremities
c. A faster than usual heart rate
d. Feelings of lightheadedness
Rationale: Numbness of the extremities is common sign of Vit B12 deficiency.
26. Ms. Tan was diagnosed of iron deficiency anemia due to chronic blood loss. Nursing actions include all of the
following, except:
a. assess diet for inclusion of foods rich in iron
b. use Z-track method for deep IM injection of iron in conjunction with oral iron
c. determine activities that causes fatigue, assist in developing schedule of activity, rest periods & sleep
d. elevate head of bed & provide supplemental 02 as ordered
Rationale: Iron tablets should be stopped for a week after an iron infusion because the iron in them will not be
absorbed by the body. If you are having more than one iron infusion then stop the iron tablets during the
course of treatment as well
27. Ms. Tan is prescribed with iron supplements. She is asking for what foods must be avoided while on iron
supplementation. Select the food/foods that may be taken in by Ms. Tan.
a. Egg
b. Spinach
c. Coffee
d. Dark chocolate
e. Almonds
 Rationale: Inhibitors of iron absorption include phytate, which is a compound found in plant-based diets that
demonstrate a dose-dependent effect on iron absorption. Polyphenols are found in black and herbal tea, coffee,
wine, legumes, cereals, fruit, and vegetables and have been demonstrated to inhibit iron absorption. Apr 21,
2022 Biochemistry, Iron Absorption - StatPearls - NCBI Bookshelfhttps://www.ncbi.nlm.nih.gov ›
28. The nurse administers oxygen at 2 L/minute via nasal cannula to a client with emphysema. The nurse should
observe the client closely for:
a. Cyanosis and lethargy
b. Anxiety and tachycardia
c. Hyperemia and increased respirations
d. Drowsiness and decreased respirations
Rationale: Clients with COPD (chronic obstructive pulmonary disease) respond only to the chemical stimulus
of low oxygen levels. Administration of high concentrations of oxygen will eliminate the stimulus to breath,
leading to decreased respirations and lethargy.
29. When assessing an individual with a spontaneous pneumothorax, the nurse should expect dyspnea and:
a. Hematemesis
b. Unilateral chest pain
c. Increased chest motion
d. Mediastinal shift toward the involved side
Rationale: Sudden chest pain occurs on the affected side; it may also involve the arm and shoulder
30. When a client suffers a complete pneumothorax, there is a danger of a mediastinal shift. If such a shift occurs,
it may lead to:
a. Infection of the subpleural lining
b. Decreased filling of the right heart
c. Rupture of the pericardium or aorta
d. Increased volume of the unaffected lung
Ratioanle: Pressure within the pleural cavity causes a shift of the heart and great vessels to the unaffected side.
This not only decreases the capacity of the unaffected lung but also impedes the filling of the right side of the
heart and leads to a decreased cardiac output.
31. The physician inserts a chest tube in a client who has been stabbed in the chest and attaches it to a two-
chamber closed-drainage system. When caring for the client, the nurse should:
a. Apply a thoracic binder to prevent tension on the tube
b. Observe for fluid fluctuations in the water-seal chamber
c. Clamp the tubing to prevent a rapid decline in pressure
d. Administer morphine sulfate, because the client will be agitated\
Rationale: Fluctuations occur with normal inspiration and expiration until the lung is fully expanded. If these
fluctuations do not occur, the chest tube may be clogged or kinked; coughing should be encouraged.
32. During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. The nurse
should expect:
a. The client’s pupils to become dilated
b. The client to experience bronchodilation
c. A decrease in gastric secretions
d. A drop in the client’s heart rate
Rationale: During a bronchoscopy, vasovagal response may be caused stimulating the pharynx which, in turn,
may cause stimulation of the vagus nerve. The client may experience a sudden drop in the heart rate leading to
syncope.
33. Following pneumothorax, a client receives a chest tube attached to a chamber chest drainage system. During
the night, the client becomes disoriented, gets out of bed, and steps on the drainage device, causing it to crack
open and lose its seal. The nurse should immediately:
a. Clamp the chest tube close to the client’s thorax
b. Attach the chest tube directly to low wall suction
 c. Place the device on a sterile field and call the physician
d. Place the end of the chest tube in a container of sterile water
Rationale: When a chest drainage system cracks open, the closed system between the pleural space, and the
device is broken. This will allow air to move through the tubing into the pleural space, exacerbating the
pneumothorax.
34. When caring for a patient who is receiving mechanical ventilation with positive end expiratory pressure
(PEEP), which of the following blood test results would indicate to
a nurse that the treatment is having the desired effect?
a. PaO2, 88 mm Hg
b. pCO2, 50 mm Hg
c. Oxygen saturation, 86%
d. HCO3 20 mEq/L
Rationale: Increased O2 levels in the blood as manifested by PaO2 within 80-100mmHg is the goal of
mechanical ventilation.
35. Which of the following would be an appropriate expected outcome for an elderly client recovering from
bacterial pneumonia?
a. A respiratory rate of 25 to 30 breaths per minute
b. The ability to perform ADL’s without dyspnea
c. A maximum loss of 5 to 10 pounds of body weight
d. Chest pain that is minimized by splinting the ribcage.
Rationale: An expected outcome for a client recovering from pneumonia would be the ability to perform
ADL’s without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/minute indicates the client is
experiencing tachypnea, which would not be expected on recovery. A weight loss of 5-10 pounds is
undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from
pneumonia should experience decreased or no chest pain.
36. You are assisting Dr. Gregorio in the removal of a chest tube. You know that your patient has understood the
pre-operative instruction if she performs which of the following?
a. Exhale slowly
b. Perform the Valsalva maneuver
c. Stay very still
d. Inhale and exhale quickly
e. Inhale deeply and hold for at least 5 seconds.
Rationale:Perform the Valsalva maneuver. When the chest tube is removed, the client is asked to perform the
Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight
dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the
breath while the tube is removed.
37. Mike Ramos,56 years old, is admitted in the ICU due to respiratory failure due status asthmaticus. He is on
mechanical ventilation and is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which
assessment finding indicates that the patient needs another pancuronium dose?
a. Leg movement
b. Fighting the ventilator
c. Finger movement
d. Lip movement
Rationale: Fighting the ventilator-Pancuronium, a non-depolarizing blocking agent, is used for muscle
relaxation and paralysis. It assists mechanical ventilation by promoting endotracheal intubation and paralyzing
the patient so that the mechanical ventilator can do its work.
38. There are 4 patients in the the ICU at this time. Who among these 4 patients is at MOST risk for developing
ARDS and has the worst prognosis?
a. A 52-year-old male patient with a pneumothorax.
b. A 48-year-old male being treated for diabetic ketoacidosis.
 c. A 69-year-old female with sepsis caused by a gram-negative bacterial infection.
d. A 30-year-old female with cystic fibrosis.
Rationale: The answer is C. Sepsis is the MOST common cause of ARDS because of systemic inflammation
experienced. This is also true if the cause of the sepsis is a gram-negative bacterium (this also makes the
infection harder to treat…hence poor prognosis). With sepsis, the immune cells that are present with the
inflammation travel to the lungs and damage the alveolar capillary membrane leading to fluid to leak in the
alveolar sacs.
39. Your ICU team is having your rounds to a patient with acute respiratory distress syndrome. As the nurse you
know that prone positioning can be beneficial for some patients with this condition. Which findings below
tells the team that this type of positioning was beneficial for your patient with ARDS? Select all that apply.
a. Improvement in lung sounds
b. Development of a V/Q mismatch
c. PaO2 increased from 59 mmHg to 82 mmHg
d. PEEP needs to be titrated to 15 mmHg of water
Rationale: The answers are A and C. Prone positioning helps improve PaO2 (82 mmHg is a good finding)
without actually giving the patient high concentrations of oxygen. It helps improves perfusion and ventilation
(hence correcting the V/Q mismatch). In this position, the heart is no longer laying against the posterior part
of the lungs (improves air flow…hence improvement of lung sounds) and it helps move secretions from other
areas that were fluid filled and couldn’t move in the supine position, hence helping improve atelectasis
40. A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the
following instructions would be appropriate for the nurse to give the client?
a. “Use your nasal decongestant spray regularly to help clear your nasal passages.”
b. “Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.”
c. “It is important to increase your activity. A daily brisk walk will help promote drainage.”
d. “Keep a diary when your symptoms occur. This can help you identify what precipitates your
attacks.”
Rationale: D. “Keep a diary when your symptoms occur. This can help you identify what precipitates your
attacks.”It is important for clients with allergic rhinitis to determine the precipitating factors so that they can
be avoided. Keeping a diary can help identify these triggers. Patients often underestimate the severity of this
condition and fail to seek medical therapy. It is important to adequately control AR, especially due to the link
between AR and asthma, with poor control of rhinitis predicting poor control of asthma.
41. After receiving report from the previous shift, which of the following clients would you assess first?
a. The 85-year-old client with a history of 3-pound weight gain since yesterday and noted
increased dyspnea
b. The 70-year-old type 2 diabetic client with a history of mitral valve prolapse and who is scheduled
to receive IV antibiotics
c. A 60-year-old woman with a pacemaker who has a heart rate of 64 and 50% pacemaker capture
d. A 45-year-old woman scheduled for a thallium scan who currently has a first-degree heart block
Rationale: This client is showing signs of heart failure. The condition of all other clients is stable.
42. You are assigned a client from recovery who has just undergone coronary artery bypass. All of the following
are orders for this client. Which would you do first?
a. Measure mediastinal tube drainage hourly and call the physician if drainage exceeds 150 mL/hr.
b. Give atropine 0.5 mg IV as needed for heart rate less than 50 beats/min.
c. Perform neurologic checks every hour for 1 hours, then every 2 hours.
d. Obtain a pulmonary wedge pressure every 4 hours and adjust IV fluids according to unit policy.
Rationale: Obtaining a baseline neurologic status is an essential assessment in initial care of the postoperative
client. This baseline helps determine whether there is a decline or progression of the client’s neurologic status
in the future.
43. Romano Pao,54 years old, is being instructed on the use of elastic stockings. The nurse should teach the client
that the stockings should be:
a. Alternately kept on 2 hours and off 2 hours
 b. Worn only at night when activity is lessened
c. Put on before getting out of bed in the morning
d. Left in place until the physician advises otherwise
Rationale: Support hose apply external pressure on the veins, preventing the retrograde pressure or flow that
may occur in the standing or sitting positions; applications before arising prevents the veins from having the
opportunity to become engorged.
44. A 49 year old patient admitted due to PVD is asking why should he stop smoking. You are aware that the most
appropriate explanation would be because nicotine: T
a. Constricts the superficial vessels, dilating the deep vessels
b. Constricts the peripheral vessels and increases the force of flow
c. Dilates the superficial vessels but constricts the collateral circulation
d. Dilates the peripheral vessels, causing a reflex constriction of visceral vessels
Rationale: Constriction of the peripheral blood vessels and the resulting increases in blood pressure impair
circulation and limit the amount of oxygen being delivered to body cells, particularly in the extremities.
45. When obtaining data from a client with thromboangiitis obliterans (Buerger’s disease), the nurse would expect
the client to demonstrate or report:
a. Easy fatigue of extremities, continuous claudication
b. General blanching of skin, intermittent claudication
c. Intermittent claudication, burning pain after exposure to cold
d. Burning pain precipitated by cold exposure, fatigue, blanching of skin
Rationale: Buerger’s disease (Thromboangiitis obliterans) is characterized by vascular inflammation, usually
in the lower extremities, leading to thrombus formation. As a result of impaired circulation, there is burning
pain and intermittent claudication.
46. A client asks what the coronary arteries have to do with angina. When determining the answer, the nurse
should take into consideration that the coronary arteries:
a. Supply blood to the endocardium
b. Carry blood from the aorta to the myocardium
c. Carry reduced-oxygen-content blood to the lungs
d. Carry high-oxygen-content blood from the lungs toward the heart
Rationale:The two coronary arteries are the first branches of the aorta and carry blood with a high oxygen
content to the myocardium.
47. Nitroglycerin SL is prescribed for angina pain. When teaching how to use a nitroglycerin, the nurse tells the
client to place 1 tablet under the tongue when pain occurs and to repeat the dose in 5 minutes if pain persists.
The nurse should also tell the client to:
a. Place 2 tablets under the tongue when intense pain occurs
b. Swallow 1 tablet and place 1 tablet under the tongue when pain is intense
c. Place 1 tablet under the tongue 3 minutes before activity and repeat the dose in 5 minutes if
pain occurs
d. Place 1 tablet under the tongue when pain occurs and use an additional tablet after the attack to
prevent recurrence
Rationale:Anginal pain, which can be anticipated during certain activities, may be prevented by dilating the
coronary arteries, immediately before engaging in the activity.
48. Cong Tebee, 56 years old, a client who has a myocardial infarction is in the coronary unit on a cardiac
monitor. The nurse observes ventricular irritability on the screen. The nurse should prepare to administer:
a. Digoxin (Lanoxin)
b. Furosemide (Lasix)
c. Lidocaine (Xylocaine)
d. Levarterenol bitartrate (Levophed)
Rationale:Lidocaine hydrochloride (Xylocaine) decreases the irritability of the ventricles and is used in the
treatment of ectopic beats originated by a ventricular focus.
49. Arman is brough to the ED complaining of chest pain. You perform assessment. Which of the following
symptoms is MOST characteristics of an AMI?
a. Colic-like epigastric pain
b. Sharp, well localized unilateral chest pain
c. Severe substernal pain radiating down the left arm
d. Sharp burning chest pain moving from place-to-place
Rationale: Further description is crushing, may radiate and unrelated to emotion or exercise. B maybe
musculoskeletal in origin. D maybe related to pyrosis.
50. Ramzon is admitted for treatment of CHF. Dr Sy orders NSS 125cc per hour and CVP reading q 4 hours. 16
hours after admission, patient’s CVP is 3 cm/H2O. Which of the following assessment of the patient’s fluid
status, if made by the nurse is MOST accurate?
a. Patient has received enough fluid
b. Patient’s fluid status remained unaltered
c. Patient has received too much fluid
d. Patient needs more fluids
Rationale: Result reveals hypovolemia. The normal CVP is 4-10cmH2O